Assessment of the amputee: Difference between revisions

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Postoperatively the assessment should also include information about the quality of the residual limb (stump) as this will have an impact on the prosthetic rehabilitation potential for the patient. Wound condition, oedema, stump length, cut end of bone (prominent or not), skin perfusion, sensation, tenderness, stump shape, redundant tissue, mobility of scar and pain should all be considered<ref>Roehampton stump score- A method of estimating the quality of stump for prosthetic rehabilitation.' Presented by Dr Sooriakumaran at ISPO world congress in Hyderabad 2013</ref>.
Postoperatively the assessment should also include information about the quality of the residual limb (stump) as this will have an impact on the prosthetic rehabilitation potential for the patient. Wound condition, oedema, stump length, cut end of bone (prominent or not), skin perfusion, sensation, tenderness, stump shape, redundant tissue, mobility of scar and pain should all be considered<ref>Roehampton stump score- A method of estimating the quality of stump for prosthetic rehabilitation.' Presented by Dr Sooriakumaran at ISPO world congress in Hyderabad 2013</ref>.


== ICF and outcomes measures<br>  ==
== ICF and outcome measures<br>  ==


The functional impairments affect many facets of life including but not limited to: the activity of daily living, mobility, body function and structure. The introduction of the International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly in May 2001 provides a globally accepted framework and classification system to describe, assess and compare function and disability.<br>  
The functional impairments affect many facets of life including but not limited to: the activity of daily living, mobility, body function and structure. The introduction of the International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly in May 2001 provides a globally accepted framework and classification system to describe, assess and compare function and disability.<br>  

Revision as of 23:58, 11 May 2015

Assessment[edit | edit source]

Assessment of a patient having an amputation should begin as early as possible, ideally preoperatively, by the whole multi-disciplinary team in order to prepare the patient, maximise the potential outcome of the procedure both surgically and functionally. In fact the decision to amputate should be made by this team where ever possible[1][2] . This could even be before admission to hospital for the surgery, especially important if there are issues associated with wheelchair accessibility to / within the home and likely support required.

Why Assess?[edit | edit source]

  • To assess the most appropriate level of amputation for the individual, not only according to tissue viability but also the likely future potential mobility the patient may have. For example: Is preservation of the knee joint paramount? Usually this would be the ideal in order to maximise function and future mobility potential but, if it is fixed in flexion and distally likely to be a pressure area if patient is not mobile maybe this is not the case. On the other hand it may still be worth preserving if the contralateral limb is also likely to require amputation in the near future at a higher level and the use of a trans-tibial prosthesis on the first side would facilitate independent transfers and safety in sitting.
  • To prepare and inform the patient and their family / carers for the surgery, hospital stay and rehabilitation. Leaflets are available such as those produced by the Circulation Foundation on many areas such as peripheral vascular disease, intermittent claudication, angioplasty and stenting, bypass surgery and amputation to support local information.
  • To discuss realistic potential level of mobility with patient, family and carers, whether this is likely to be using a wheelchair or prosthesis depending on the findings of the assessment. It is important to be open and realistic from the start in order to facilitate adjustment to their new situation and to minimise problems resulting from misinformation. Usually patients will experience a lower level of function following an amputation than previously, especially if having a higher level of amputation such as trans-femoral.
  • To order appropriate wheelchair and stump board if needed so it is available as soon as possible.
  • To optimise pain relief pre op and post op. Discuss pain relief and possible phantom limb sensation and pain post op.
  • To refer to other members of the team as required such as Occupational Therapist, Psychologist or Counsellor, Podiatrists, Prosthetic service, Dietician, Specialist nurses such as Tissue viability or District nursing, Wheelchair services, Social services and other medical specialities such as Diabetology, Psychiatry, Elderly care, Neurology or Rehabilitation medicine.
  • To offer support from other amputees if appropriate either locally or through national organisations such as The Limbless Association in UK and The Amputee Coalition in America or online support networks.
  • To begin discharge planning - whether the patient will be able to return home or will need rehousing or adaptations to be made, a care package or admission to a residential or nursing home.
  • To plan pre and postoperative physiotherapy intervention through setting of realistic goals with the patient.

Information can be gained from many sources as well as the medical and nursing notes, patients, carers and those involved in the patient's care prior to admission. Assessment is never a one off exercise but an ongoing process. See Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation [3].

The following may be an example of the elements of assessment:

Past Medical History[edit | edit source]

  • Diabetes and its associated complications: particularly those that may affect the patient’s functional ability and potential for prosthetic limb use such as neuropathy (upper and lower limbs), retinopathy, poor glycaemic control and condition of the contralateral limb
  • Cardiac history / exercise tolerance
  • Renal function / dialysis potentially resulting in fluctuating stump volume
  • Respiratory function / exercise tolerance / shortness of breath on exercise
  • Previous stroke and any residual effects
  • Previous trauma and associated surgery
  • Arthritis and associated limited range of movement, pain or weakness
  • Previous joint surgery
  • Previous vascular investigations such as doppler, angiography, CT or MRA (e.g. video of MRA showing occlusion and collateral circulation)
  • Previous vascular interventions such as angioplasty, thrombolysis, aneurysm repair and bypass surgery
  • Allergies: may affect treatment (especially dressings), therapy and prosthetic materials used

Medication, especially:[edit | edit source]

Present Medical History:[edit | edit source]

  • Reason for amputation: Peripheral arterial disease, trauma, tumour, congenital deformity
  • Associated medical problems: ulcers, fractures, soft tissue injuries
  • History of deterioration of limb: acute or chronic
  • Skin condition, perfusion, sensation, rest pain
  • Current functional ability: self-care, mobility (use of aids, distance, reasons for limitations), activities of daily living
  • Smoking history
  • Pain
  • Cognitive ability
  • Claudication history
  • Vision and hearing ability

Social History:[edit | edit source]

  • Cohabitants / dependents: age, health, ability to assist / care / support the patient or is the patient a carer?
  • Housing: Type of property, ownership, access internally and externally, previous adaptations, layout, position of bathroom facilities and bedroom
  • Occupation: Type of work, mobility required, wheelchair accessibility, travel to and fro, pressure to return, adaptations required, retraining necessary
  • Hobbies and interests: Sedentary, social and more active including sports
  • Driving: manual or automatic, type of vehicle
  • Current social services support / support from family and friends
  • Existing wheelchair use, duration, for what purpose

Physical assessment:[edit | edit source]

  • Joint integrity and presence of contractures, especially of flexors of hip and knee joints
  • Muscle power and range of movement of upper and lower limbs as well as trunk – especially core stability
  • Hand function – will they be able to donn and doff a prosthesis, use a manual wheelchair
  • Balance in sitting and standing
  • Ability to transfer and mobilise
  • Standing tolerance
  • Presence of scar tissue / skin grafts
  • Condition of the contralateral limb / foot
  • Patients expectations of planned surgery: For some it will be an elective amputation following a prolonged disability or period of treatment, for others it may be an acute episode resulting in an emergency amputation. Patients expectations may be well informed and realistic but not always. Sometimes they can be over optimistic as to the ease and speed of prosthetic rehabilitation, lack of discomfort, future mobility levels but equally they can sometimes be overly pessimistic and realistic plans and goal setting is essential.
  • Psychological and emotional state: During rehabilitation the advice and support given by the team, family and others amputees are very helpful and means that they may not require specialist counselling but some patients do require additional support. Every patient’s response to their amputation will be unique. Their coping strategies or reactions may well change over their rehabilitation period and beyond and as therapists we need to be aware of possible responses that may be of concern such as denial, withdrawal, suppression, regression, projection and displacement[4]. Timely referral is needed on to the appropriate speciality if required.

Postoperatively the assessment should also include information about the quality of the residual limb (stump) as this will have an impact on the prosthetic rehabilitation potential for the patient. Wound condition, oedema, stump length, cut end of bone (prominent or not), skin perfusion, sensation, tenderness, stump shape, redundant tissue, mobility of scar and pain should all be considered[5].

ICF and outcome measures
[edit | edit source]

The functional impairments affect many facets of life including but not limited to: the activity of daily living, mobility, body function and structure. The introduction of the International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly in May 2001 provides a globally accepted framework and classification system to describe, assess and compare function and disability.


WHO ICF framework.jpg

Source: Short version booklet of the International Classification of Functioning, Independence and Health (WHO 2001) . ISBN / WHO Reference Number 92 4 154544 5 www.who.int/classifications/icf/en/; ISBN / WHO Reference Number 92 4 154544 5

ICF "World Health Organisation ICF Framework- amputee elements" in Appendix 2, p 46 Amputee+Rehabilitation+Model+of+Care  ICF amputee

Outcome measures[edit | edit source]

In order to evaluate the lower limb amputation rehabilitation outcome, the use of a measurement instruments will quantify those outcomes classified within the International classification of functioning, disability and health (ICF) category of body function or structure.

Self-report  and functional measures [6]   BACPAR toolbox_version_outcomes measures

  • Activities-specific Balance confidence scale- UK (ABC-UK); The ABC -UK is a self report, quality of life outcome measure, relating balance confidence to functional activities.
  • The Amputee Mobility Predictor (AmpPro / AmpNoPro): is an instrument to Assess determinants of the Lower-Limb Amputee's Ability to Ambulate and measure function post-rehabilitation. It was developed to provide a more objective approach to rating amputees under the various "K Classifications". The test can be performed with or without the prosthesis.The AmpPro form & instructions can be viewed here AmpNoPro (In Appendix 2 for instructions).
  • Prosthetis evaluation questionaire used to describe the perception of difficulty in performing prosthetic function and mobility. The PEQ is a self-report, 82-item questionnaire developed to assess prosthetic function, mobility, psychosocial aspects, and well-being
  • Locomotor capability index questionnaire; the LCI is a self report outcome measure that forms part of the Prosthetic Profile of the Amputee questionnaire. The LCI assesses a lower limb amputee's perceived capability to perform 14 different locomotor activities with a prosthesis.
  • The Trinity Amputation and Prosthesis Experience Scale (TAPES), is to examine psychosocial issues related to adjustement to a prosthetic, specific demands of wearing a prosthetic and potential sources of maladjustement.
  • The Barthel scale or Barthel ADL index is an ordinal scale used to measure performance in activities of daily living (ADL). Each performance item is rated on this scale with a given number of points assigned to each level or ranking.
  •  The Prosthetic Profile of the Amputee (PPA) measures function of adult unilateral lower limb amputees (prosthetic users and nonusers) in terms of predisposing, enabling, and facilitating factors related to prosthetic use after discharge from the hospital.www.oandp.org/olc/lessons/html/SSC_06/section_07.asp
  • Additional outcomes measures; Stand up and go, L test, 2 min walking test, 6 min walking test...

AIM

  • To determine which validated instruments are available to measure global lower limb prosthetic outcomes.
  • To identify what these instruments attempt to measure.
  • To make recommendations about the use of particular outcome measures in prosthetic rehabilitation.

Various outcomes measures related to the amputee assessment can be find in the following link:

www.austpar.com/portals/gait/tools.php

Read more about Outcome Measures for Amputees

Assessment for suitability for a prosthesis[edit | edit source]

Many trans-tibial amputees will be able to use a prosthesis, even if it is only for transfers or to help with sitting balance or even for cosmetic reasons but a trans-femoral limb is very different so careful assessment is required as to whether the patient will be able to benefit from a prosthesis, particularly at this level.

Differences between trans-tibial and trans-femoral prosthetic use[edit | edit source]

Trans-tibial prosthesis Trans-femoral prosthesis
Can be donned in sitting Ideally donned in standing therefore requires balance and frequently use of both hands
Can be used to aid sit to stand Does not help patient to stand up
Aids sitting balance and transfers Can make transfers more difficult
Lower energy expenditure in gait compared with trans-femoral level[7] Higher energy consumption in gait compared with trans-tibial level
Lower risk of falling Higher risk of falling
Usually comfortable to sit in Tendency to be uncomfortable if sitting for prolonged period due to high level of socket anteriorly
Can be used purely cosmetically

 

Borderline criteria for trans-femoral prosthetic use initiated by the South Thames Regional BACPAR group and further developed by Roehampton which may be helpful:

Most important parameters to take in considerable for prosthetic fitting:

A hip flexed beyond 15 degrees makes fitting a prosthesis difficult.

For the knee depending the lenght of the stump, for xxxx

You can read more about contracture in this link www.amputee-coalition.org/inmotion/jan_feb_10/contractures.html


If patients are unable to achieve the following they are unsuitable for prosthetic rehabilitation:

  • Transfer independently from a seat to bed/chair/toilet and back using a standing pivot transfer.
  • Push up from sitting in wheelchair to standing independently in parallel bars.
  • Have independent standing balance within parallel bars (patients may need to be able to stand for up to 5 minutes for prosthetic casting).
  • Cognitively unimpaired i.e. be able to follow instructions, process new information and remember it over a period of time. (A CAPE assessment can be organised if needed).
  • With the aid of an early Walking Aid (such as a PPAM aid or Femurette) mobilise within the parallel bars. The patient should be able to achieve 6-10 lengths, repeatedly, throughout a treatment session on a regular basis during their initial phase of rehabilitation.

The following areas would cause concern and would impact on prosthetic rehabilitation :

  • Muscle strength scale 4 (Oxford) in all 4 limbs
  • Poor hand dexterity, with patient unable to manage velcro fastenings, straps or knee locking mechanisms
  • Patient unable to wash and dress themselves independently
  • Other pathologies e.g. CVA, R.A, O.A, Respiratory problems, poor Cardiovascular state
  • Poor motivation
  • Issues of concern around social support and home environment


Resources[edit | edit source]


References[edit | edit source]

  1. Lower Limb Amputation: Working Together. NCEPOD report 2014
  2. The Vascular Society of Great Britain and Ireland. Quality Improvement framework for major amputation surgery 2010. Vascular Society of Great Britain and Ireland.
  3. Broomhead P, Dawes D, Hancock A, Unia P, Blundell A, Davies V. 2006. Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation. Chartered Society of Physiotherapy, London
  4. Barsby P, Ham R, Lumley C, Roberts C. 1995. Amputee management – a handbook. Kings college School of Medicine and Dentistry, London
  5. Roehampton stump score- A method of estimating the quality of stump for prosthetic rehabilitation.' Presented by Dr Sooriakumaran at ISPO world congress in Hyderabad 2013
  6. http://www.oandp.org/jpo/library/2006_01S_013.asp
  7. Bowker HK, Michael JW (eds): Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons, edition 2, 1992, reprinted 2002.